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The Royal College of Psychiatrists Improving the lives of people with mental illness

Are medical skills lost?

Doctors considering core psychiatric training (CPT) may be anxious that hard-won medical skills will disappear. Whilst it may be true that, as your training progresses, the opportunities and responsibility for practical procedures and physical examination decrease, psychiatrists will always be medical doctors, specialising in mental health. Medical training instils a systematic way of approaching health problems. This persists in psychiatry with the necessary addition of lateral thinking and a biopsychosocial approach. Medical skills are neither redundant nor lost in translation, but adapted and added to along the way and it is more accurate to consider that what you lose with the one hand, you gain with the other.

A good way of illustrating the medical skills required in psychiatry is to consider the senses all clinicians rely on. The examination of the mental state calls upon you to move beyond inspection to a more sustained observation of appearance and behaviour. This observation includes recording visual information such as cleanliness, dress, dentition, agitation, distractibility, movements and mannerisms, eye contact and body language. The discipline of recording this information develops a skill with real clinical currency (think about someone you live with – can you remember what they were wearing this morning?)

When listening to the patient’s own words, take the time to record verbatim examples. The narrative should not be discarded, as it is likely to contain personal meaning however well hidden. Everyone has their own communication style and psychiatrists often need to be flexible in order to get people talking. Once you have started this process, open questions help the individual to identify what is important to them and closed questions can be used to define, clarify and check your understanding. Smells reflect the life being led and thus self-neglect, fear or the telltale presence of spent alcohol pooling in the pores can be indicators.

All medical specialties accord attention and value to a clinical hunch, and the equivalent in psychiatry is probably gut feeling. However, the decision-making process is complex, and clinical intuition (based on the foundations of a good history and examination) should be supplemented with collateral information, appropriate investigations and objective clinical tools. Touch may literally consist of a handshake but, as a doctor, being touched emotionally (and thus left with an aftertaste) is commoner than is admitted. Medical students asked “how did it make you feel?” may experience initial discomfort, but the cliché has valid and honest roots. Cultivating self-awareness and recognising the validity of your own reactions to others contributes to successful clinical practice. Although these skills apply to other medical specialities, psychiatry uniquely recognises them and incorporates training and experience in psychotherapy and a weekly hour of consultant supervision as part of CPT. The importance of human interactions is at the very heart of training.

Dr David Brunskill

Specialty Registrar in forensic psychiatry

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